Loss Description:
(Please provide a brief description of each occurrence, the date of loss and the
amount of loss.)

Inland Marine (Mobile Equipment) Information

Number of Items to be Insured:

Item 1

Equipment Description:

Equipment Serial Number:

Cost New:

Item 2

Equipment Description:

Equipment Serial Number:

Cost New:

Item 3

Equipment Description:

Equipment Serial Number:

Cost New:

Item 4

Equipment Description:

Equipment Serial Number:

Cost New:

Item 5

Equipment Description:

Equipment Serial Number:

Cost New:

Loss Detail:

Yes, we can provide loss detail

Loss Description:
(Please provide a brief description of each occurrence, the date of loss and the
amount of loss.)

Commercial Auto Information

Driver Information

How Many Drivers:

Driver 1

First Name:

Last Name:

Gender:

Date of Birth:

/
/

Drivers License Number:

Drivers License State:

Driver 2

First Name:

Last Name:

Gender:

Date of Birth:

/
/

Drivers License Number:

Drivers License State:

Driver 3

First Name:

Last Name:

Gender:

Date of Birth:

/
/

Drivers License Number:

Drivers License State:

Driver 4

First Name:

Last Name:

Gender:

Date of Birth:

/
/

Drivers License Number:

Drivers License State:

Vehicle Information

How Many Vehicles (include trailers):

Vehicle 1

Vehicle Year:

Make:

Model:

VIN / Serial Number:

Vehicle Use:

Comprehensive Deductible:

Collision Deductible:

Vehicle 2

Vehicle Year:

Make:

Model:

VIN / Serial Number:

Vehicle Use:

Comprehensive Deductible:

Collision Deductible:

Vehicle 3

Vehicle Year:

Make:

Model:

VIN / Serial Number:

Vehicle Use:

Comprehensive Deductible:

Collision Deductible:

Vehicle 4

Vehicle Year:

Make:

Model:

VIN / Serial Number:

Vehicle Use:

Comprehensive Deductible:

Collision Deductible:

Bodily Injury Liability Limits:
(Per Person / Per Accident)

Property Damage Liability Limits:
(Per Accident)

Uninsured Motorist Coverage:

Underinsured Motorist Coverage:

Loss Detail:

Yes, we’ve reported an loss in the last five years

Loss Description:
(Please provide a brief description of each occurrence, the date of loss and the
amount of loss)

Workers Compensation Information

Employers Liability Limits:

States of Operation:
(hold down CTRL to select multiple)

Loss Detail:

Yes, we’ve reported an loss in the last five years

Loss Description:
(Please provide a brief description of each occurrence, the date of loss and the
amount of loss)

Remarks or Comments

Thank You!

Thank you for taking the time to fill this form out completely. Please note that
we understand that your detailed information is very important and is private. We
took every precaution to keep it that way. Use of your information for marketing
or any other purpose other than insurance underwriting is strictly prohibited.

Your understanding of the above and authorization for us to use your detailed information
will allow us to service your policy.

Please check the following:

Yes, I understand the above paragraph and authorize Hancock Insurance to service my policy